Y
A Report on Koch s Treatment
of Tubercular Disease.
BY
J. W. SPEINGTHOEPE,
M.A., M.D. Melb., M.R.C.P. Lond.
Physician to the Melbourne Hospital.
Lecturer on Therapeutics in the University of Melbourne.
READ BEFORE THE VICTORIAN BRANCH OF THE BRITISH
MEDICAL ASSOCIATION, MARCH 2, 1S91.
Reprinted from the "Australian Medical Journal," 1891.
Melbourne
Stillwell and Co., Printers, 195A Collins Stj
21 OCT
\
A REPORT ON KOCH'S TREATMENT OF TUBER- \ .
CULAR DISEASE.
J'T1 OCT 91
By J. W. Springthorpe, MA., M.D., M.R.C.P.
I am hopeful that the following report, embodying the results
of a month's study of the effects of Koch's remedy in tubercular
disease at the head-quarters of treatment in Berlin and London,
will prove of assistance to the profession in Victoria, in arriving
at a just estimate of the therapeutic value of this newest and most
potent of drags. When we consider the gravity of the issues
involved, and the claims of the speaker, there is little wonder that
the civilised world has been in spirit, if not in body, to Berlin to
hear Koch. Eor tubercular disease follows man and beast almost
everywhere. In the old world it continues to slay its millions,
and in this Australia of ours, " though the rural parts enjoy a
comparative imnmnity, consumption figures in most of our returns
as the greatest single cause of death, whilst our principal towns
show a proportion of phthisical deaths nearly equal to that of
many European cities " (McLaurin). Hence, when Koch, the
distinguished discoverer of the cause of the disease, the man most
competent to speak, and, as shown by previous experience, most
cautious in utterance, announced the discovery of a remedy potent
to cure, it was only to be expected that the hopes of all would be
raised indeed. And though the time has not yet come when
anything like finality has been reached, it seems to me no
exaggeration to say that in the past four months, we have learnt
more of the effects of this new treatment than could have been
gained from four years of ordinary observation, and of more or less
isolated experiments. For no drug has ever before met with
anything like such a reception, has been anything like so widely
tested, so accurately reported upon, or subjected to such a furnace
of criticism. It is time, indeed, to i-eport progress, and to discuss
some, at least, of the indications for and against its therapeutic use.
The Nature of the Remedy. — After the little delay necessitated
by the compulsory disclosure of his experiments, Koch himself
has told us that his remedy consists of salts, pigment, and
unknown extractives obtained from pure cultivations of the
tubercle bacillus, by the help of forty to fifty per cent, glycerine,
the salt and pigment being unimportant ingredients, retained only
1
from questions of expense, and the extractives, the active principle,
being present only in a fraction of -1 per cent. But we are not
told in what media the bacilli have been cultivated, whether in
blood-serum, human or otherwise, or different glycerine peptone
cultures, though, as we know, the results of growth may vary
considerably with the difference of the media. It may be, it
probably is, the case, that Koch's cultures are from the most
suitable media, but of this, we have as yet no satisfactory
guarantee. Indeed, the best mode of preparation may yet have
to be discovered. And though the genius of Koch as an
experimentalist, shines out through every step of the long journey
through which he has travelled before he has reached his present
goal, yet it seems probable that he owes the germinant idea to
France, and the successful method to England. For it was in the
laboratory of the immortal Pasteur that it was first discovered
how the weakened cultivations of anthrax bacilli rendered the
animal into which they were injected immune against anthrax ;
and how attenuated emulsions of the spinal cords of rabid rabbits,
when progressively injected, conferred immunity from the idtimate
effects of hydrophobia. The indebtedness of Koch to Pasteur is
generally recognised. But his probable indebtedness to Hankin, of
Cambridge, for his final success, is not yet so generally understood.
I say probable indebtedness, because the matter will remain
unsettled until Koch fully discloses his method. As this is so
little known, I take the liberty of dwelling somewhat upon it. It
had been known as far back as 1887 at least, that immunity
against various diseases could be produced by the injection of the
soluble products of the life of microbes. But until Hankin's
time, all isolating experiments were conducted with the ptomaines
made by the microbes. And though many such were isolated, no
cases were ever recorded in which immunity had been produced
thereby. It was in October 1889, that the observer mentioned,
isolated from anthrax cultures, an albumose — a poisonous proteid
of a totally different nature to the ptomaines — and by means of
this albumose, produced immunity against anthrax. This discovery
completely altered the methods of experimentation. Shortly after-
wards, Brieger and Frankel, working in the same laboratory, and
abandoning old methods in favour of others practically of the
same nature as Hankin's, isolated similar bodies from cultures of
tetanus, cholera, and typhoid, though apparently without then
succeeding in the production of immunity thereby. In May 1S90,
5
Dr. Sydney Martin reported the separation of two poisonous
albumoses, and one poisonous alkaloid from anthrax cultures ;
whilst prior to July 1890, Professor Bebes had discovered
albumoses in glanders, in rabies, and in pigeon diphtheria. It
seems probable, therefore, that Koch himself had his attention
turned from ptomaines to albumoses by these and similar dis-
coveries, and following these newer methods, came upon the great
discovery with which the world has been ringing. Everything,
indeed, points in this direction. Like Brieger and Fr'ankel's, his
extract is first called a " tox-albumen ; " it is denied that it is a
ptomaine, whilst his description of its properties suggests strongly
the albumose reactions. It will be interesting, indeed, to know
the truth upon this point.
One other point of interest follows from this knowledge of
the mode of preparation of the remedy. It is that the strength
of the lymph, as at present produced, can scarcely be a constant
quantity. Koch himself takes the responsibility that all lymph
bearing his name, is both reliable and efficient ; but its relative
efficiency certainly varies. This variability accounts, in my
opinion, for numerous clinical discrepancies, as well as many
personal disappointments, and imposes upon all the necessity of
carefully testing the strength of one sample, prior to drawing
conclusions. With us, indeed, another factor may come into play
in the influence of continued heat upon the undiluted as well as
the diluted lymph. This may be nil, or may be very great ; Dr.
Libbertz thinking the former, and Professor Frankel inclining to
the latter. As some precaution, I have divided my seven bottles
into two divisions — one I have kept at the temperature of the
surrounding air all through the tropics ; the other, at a standard
temperature, a little below 70°.
The Effects of the Remedy. — Upon this point, a very large quantity
of valuable evidence has been already collected — sufficient, indeed,
to warrant some very definite conclusions.
(1) Clinically, the effects of the drug in cases of tuberculous
disease, have been exhaustively collated, almost all nationalities
and shades of thought being well represented. There can be little
need, however, for me to do more than touch suggestively upon what
Koch and subsequent observers have made known to all. The
f/eneral reaction, which is almost invariably present, is well
exemplified in its different degrees in the charts which are
arranged round the room, and which represent cases under
G
treatment in the Friedrichshain, Urban, Cbarite, and University
Clinics. I propose leaving them on view during the week, so that
any member interested can at his leisure study the changes
produced in temperature, pulse, respiration, <fec. I am indebted
to Dr. Mullen for the translation of the brief epitome, which gives
the clinical facts present during the course of treatment.
Undoubtedly variations occur in the reports published by different
observers. Some of these discrepancies are probably due to
variations in the strength of the lymph. Such for example seem
the negative results, obtained by Schroetter, Billroth, Kaposi, and
others, in Vienna, during November and December. Errors in
administration and variations in the clinical features of the case
may, and probably do, account for other differences, whilst others
remain due, perhaps, as Giittmann suggests, to idiosyncrasy, 1 n
not a few, from some unexplained cause, the reaction " hangs fire "
for some twenty-four hours, and to want of allowance for this
peculiarity may be fairly attributed some serious effects where the
injection was repeated before the latent period had elapsed.
Equally well known to you is the local reaction, so noticeable
and so well illustrated chromo-lithographically in the picture of
lupus which I show, taken from the British Medical Journal, of
January 3, 1891. It is scarcely necessary to remind you that this
local reaction is similarly present in whatever locality the tuber-
culous tissue may be found, whether lung, bone, joint, gland,
larynx, meninges, intestines, kidneys, or what not; with the
production, of course, of symptoms varying with the organ, its
function, and the severity of the reaction. This local reaction
indeed is the direct result of the action of the remedy upon
peri-tubercular tissues; whilst the general reaction seems due
partly to these local changes, and partly to its effect upon vital
protoplasm in general, and the white blood cells in particular.
To complete the clinical picture, however, we must remember the
marked feeling of lien etre, which generally follows injection, the
splenic swelling, the sickness and vomiting so frequently noted, the
occasional presence of icterus, the eruption rubeoloid scarlatina-
form and herpetic j the temporary albuminuria, hematuria,
haemoptysis, diarrhoea, the changes in the number and structure of
the bacilli discharged from the system, and the changes which
Henocque describes as found in the haemoglobin. Nor must we
forget the unexpected presence of local reactions in unsuspected
positions, suggesting in most instances early and unrecognised
7
tubercular lesious but in a limited number, suggestive of fresh
infection, due possibly to the effects of injection.
(2) Almost as noteworthy, though of course much less limited
in scope, is the pathological picture as drawn by Jiirgens, Henoch,
Koranyi, Jurisch, Chiari, but above all by the master hand of the
veteran Virchow. With their discoveries you are probably only
too familiar, and for the details it will suffice to refer you to the
summary of evidence collated in Appendix A. In the limited time
at my disposal I can deal only with commentary. Virchow's
paper contains the pathological results which have exercised the
most determining influence upon the trend of public, and even
professional, opinion, and from their intrinsic importance, no less
than their ulterior effects, they merit the most careful investigation.
Tndeed, it is not too much to say, that for want of such scrutiny
they have swung the pendulum of opinion as much to the one side
of truth as the unreasoning excitement of the first few weeks had
swung it to the other. Looked at calmly, what do Virchow's
post-mortem examinations show us 1 It is true they place beyond
all doubt what may be the local results of the drug, (and such
evidence is invaluable), but this is only in certain cases, and when
the drug is administered therein in a certain manner. What then
are those cases, and what the dosage? The answer will startle
those who have judged without correction. The cases were : —
(1) Boy, 2f years old, with tubercular arachnitis and old lung
mischief, where colossal and unprecedented hyperasmia was found
to be present. In all, four doses had been given, amounting to
•002. Such cases then are evidently contra-indicated, at any rate
when the remedy is given in anything like such doses as •0005.
(2) Case of severe bone and joint tuberculosis, case of " cavity "
with carcinoma of the pancreas, and a case of pernicious anaemia
with pleurisy and slight lung mischief. None of these cases can
be said to be particularly fitted for any line of treatment — even
Koch's lymph, — and until the dosage is known, it would be useless
to attempt to draw any conclusions. (3) The sixteen cases of
phthisis, therefore, furnish the gravamen of the charge of danger
which Virchow has practically brought against Koch's remedy.
More than ever is it valuable then to ask, what were these cases,
and what the dosage ? As to the cases, all Virchow himself tells
U8 is that, with one exception of apical induration with persistent
fever (?), they were all cases in which ulcerative processes of a
greater or less extent were present. Three only have I been able
8
to trace further > — one was a case of advanced phthisis and amyloid
disease ; one of extensive phthisis, with severe pleurisy ; one of
advanced phthisis, with dropsy and albuminuria. If then these
are any fair samples, the cases were practically cases of advanced
pulmonary mischief — doubtful cases for treatment, even according
to Koch's first paper ; cases in which, according to his subsequent
paper, treatment may be dangerous and even harmful. And what
of the doses administered 1 My daily comparison of the line of
treatment adopted at the different Berlin hospitals, had already
prepared me to believe that the dosage at La Charite (of which
Virchow is pathologist) was somewhat heroic, and I feel convinced
that, when contrasted, for example, with the Moabit and the
Friedrichshain Hospitals, it will be found to be excessive in
amount, and more frequently administered ; and to some extent,
the charts exhibited to-night bear out this contention. And when
we turn to the three fatal cases under Professor Leyden, of which
I have already gathered the clinical details, we find that in the
first '1 had been administered in seven injections, in twelve days ;
in the second -006 in two injections ; and in the third up to "04
in eight doses. We have ground, therefore, for stating that
Virchow's results are largely, if not entirely, the results of
excessive doses, given in advanced cases. Criticism again is
possible with reference to his interpretation of some of the
lesions which he so well describes. We may admit, without
reserve, the local congestions, haemorrhages, actual inflammatory
processes, even extensive caseous hepatisations, and peculiar
turbid infiltrations, with tendency to excavation, to which he calls
attention, as more or less likely to occur whenever the remedy is
administered in such doses in such cases. But whilst admitting
the possibility, even the probability, of some local metastasis of
the bacilli under similar circumstances, we must not forget that
septic orgauisms also are present ; and some competent judges
ascribe the pyrexia and secondary results rather to septicaemia
than to tubercular infection, remembering that the bacilli die in
blood and lymph for want of pabulum, a fate sooner experienced
in all probability, whilst the injections are being continued.
Lastly, as to the want of effect of the lymph in certain places, such
as submiliary and solitary tubercles, it is open to question whether
the first may not have been in reality septic, whilst the latter are
distinctly stated to have been "like large lumps of cheesy matter,"
and Koch has distinctly declared in his first paper, that his lymph
9
" had no effect upon dead tissue, as for example necrotic cLeesy
masses." I have dwelt at this length upon Virchow's already
classical paper, because of the vast effect which it has exercised
upon opinion, and I leave the thoughts here suggested to your
consideration without further comment. I cannot leave this
point, however, without reminding you of the conclusions which
Th-chow himself drew from his investigations, viz., a -warning to
physicians to operate with greater caution in cases where patients
had not the strength completely to expectorate the broken-down
tissue, and the habit of doing so ; and in clinical support of the
position which I have here taken up, I would ask you to read
carefully, the results recorded by lurbringer and Giittman, at
Friedrichshain and Moabit respectively ; the latter of whom,
indeed, goes so far as to add that, "when other hospitals make
similar selection of cases, they will attain similar (favourable)
results."
(3) I must dismiss briefly the effect of the remedy upon non
tuberculous cases. That a sufficient dose will seriously affect the
healthy individual, is proved from Koch's experiment upon him-
self of *25 cc. ; the lowest limit of noticeable effect being found
also from numerous experiments to be -01 cc, when slight pains
and transient fatigue were the only symptoms produced. The
fact of such i-esults following injection in the healthy individual,
shows that in a variable, though excessive dosage, the remedy
meets with something in the healthy body upon which it can
react. It also prepares us to expect similar reactions in other
diseased states, even with much lesser doses, especially in diseases
allied to tubercle, and certainly, of course, in the large class of
cases of unrecognised tubercle. It is not surprising, therefore,
that re-actions have been stated to be present in two cases of
actinomycosis, in syphilis, carcinoma, leprosy, and many doubtful
lung cases. But after making all allowance for these, at present,
unexplained irregularities, the fact remains, that as a reliable and
delicate diagnostic agent for the recognition of tubercle in any
form or situation, Koch's lymph is at present considered to stand
without a rival.
TJie Effect of tJie Remedy upon Tubercular Disease. — For the
purpose of this paper, tubercular disease is taken to be the
expression of the lodgment of the tubercle bacillus in a suitable
soil, and its growth therein at the expense of the organism.
The bacillus we know, thanks to Koch himself. The modes
10
of entry we suspect, thanks to Koch, Cornil, Bang, Mosler,
McFadyoan, and others. But what of the soil ? That there must
be some susceptibility of the system is certain, otherwise many of us
must have ere now fallen victims. That the lodgment in any force
is a question of time, and the local fight, not always decided in
favour of the invader, is equally sure. What then is this consti-
tutional or local weakness of which the tubercle bacillus takes such
dire advantage? Evidently, it is a matter of the most delicate
bacteriological chemistry, and without claiming entire certainty
or complete accuracy upon such an unsettled point, it may be
taken that it is a weakness as deep down as the vitality of the
vital protoplasm, and especially of the white blood cells, rendering
them more or less impotent to engage the bacillus in pitched
battle. Later on again, the tubercle bacillus becomes reinforced
by other invaders, such as the streptococcus, aureus and albus,
the pus streptococcus, the microbe of pneumonia, and the like.
Tubercle then, as we find it, in general and special hospitals, in
man and beast, in surgery and medicine, in each and every part
of the system, is the theatre of operations between these germs
and their surroundings. Now, what effect has Koch's lymph upon
the different parties to the fight? (1) Upon the Constitutional
Status. — In animals, immunity from fresh attack has actually been
produced, whilst in man it remains to be seen whether an equally
good effect will be attained. Koch thinks it probable. Lister
suggests that it may be a matter of dosage. Everything points in
favour of hoping the best from continued trials. Apart from
permanent immunity, however, it seems probable that temporary
assistance is borne to the weakened system by the administration
of the lymph. (2) Upon the Bacillus. — Koch expressly stated in
his first paper that his remedy did not kill the bacillus, and
subsequent observations have corroborated his view. But,
undoubtedly, the wise use of it helps to starve the bacillus out
of existence, and finally to procure its disappearance. Equally,
undoubtedly, its reckless or unskilful use may lay fresh parts of
the system open to invasion by the tubercle and other germs, and
their lodgment therein becomes a question of conditions being
favourable. In what manner the remedy may give this assistance
we have been told by Koch, in his explanatory paper of January
15th, which I leave you to re-read at your leisure in the British
Medical Journal. It is only necessary now to add that clinical
and pathological observations in the main support his view, and to
11
remind you that in it we have a good working hypothesis, as good
indeed, and apparently as reliable as many others in ordinary
therapeutic use.
The Clinical Record of its use up to January. — To bring the
whole matter of the use of Koch's lymph succinctly before you, I
have prepared a summary in Appendix A, which contains an
abstract of the experience and opinions of some 90 observers, all
of whom have had more or less to do with its administration in
different forms of tuberculous disease. The abstract embraces the
name of the observer, the date of his communication, his experience
with the remedy, his results, and remarks. It is as complete as I
could make it with the materials at my hand, and, in my opinion,
may be taken as a fair epitome of the scientific world's experience
and opinion up to date, and as such it is brought under the notice
of those who wish rapidly to review the situation.
Personal Experience. — As regards my own experience with the
remedy, you are, no doubt, all aware, that like many thousands of
others, I have visited Berlin to ascertain for myself the exact
state of matters with reference to its therapeutic value. I
remained in Berlin for over three weeks, and then proceeded to
London for a week longer.. At Berlin I visited the Charite,
Urban, Friedrichshain, Moabit, Augusta, University, and other
Hospitals, and saw numerous cases, of all kinds, under treatment
by Bergmann, Hahn, Senator, Frankel, Fiirbringer, Sonnenberg,
Ewald, Leyden, Gerhardt, &c, with their accomplished assistants,
Schimmelbusch, Klemperer, Roth, Gumprecht, &c. To all these
gentlemen I would take this opportunity of returning my sincere
thanks for much courteous assistance ; the more appreciated
since their patience must have been sorely tried by the
previous unparalleled strain upon their good nature. By the
kindness of the British Ambassador, Sir Edward Malet, and
the English Consul-General, Baron Bleichrbder, neither of
whom I can thank too warmly, I received official permission to
inspect all hospitals, and an early supply of the lymph. Indeed I
•had my lymph before I was a week in Berlin. But, though I
was the first Australian to receive a supply, and not only anxious,
but under agreement, to return at the earliest moment, I saw that
it would be the height of folly to return until I had something
more definite to go upon, especially as too sanguine hopes had at
first been freely entertained, and the tide of opinion was as
foolishly rushing towards the other extreme. Indeed, I thought it
12
wise to still further widen the base of my observations, and feeling
fairly acquainted with the Berlin aspect of the case, to go on to
London and Paris. In London, I visited King's College Hospital
with Watson Cheyne, the Victoria Park Hospital, the London
and the Brompton Hospitals. I found that with the exception of
the first two, where Cheyne and Heron were operating at Koch's
special request, little had been done, though much was in the air.
This delay was mainly owing to the secrecy maintained by Koch
as to the nature of his lymph, and the unwillingness of the
College of Physicians, and many leading membei-s of the
profession, to depart from their traditions, and experiment with a
drug of unknown composition. Before I left, however, St. Mary's,
and the other large hospitals, were moving in the matter, and
numerous reports had been received from all the large centres in
the kingdom. Thence to Paris, where I must confess that the
opportunity of visiting Pasteur's laboratory, under the wing of
Dr. Adami, drove the tubercle question quite out of my head for
the only day at my disposal, until it was too late. It was an
inspiration to enter the rooms in which Metchnikoff, Boux, and
others had made their discoveries ; to watch Boux at work
injecting some 60 patients for hydrcTphobia ; to see the marvellous
completeness of the whole observatory, and to listen to the voice
of the immortal Pasteur.
As to the actual results which I observed myself, I have
thought it wiser to collate a few of the more interesting in
Appendix B, rather than to incorporate them with the portion of
my report which I have rapidly to read over. They will be
found, in the main, to support the favourable view which I have
taken of the remedy within the limits already denned.
The present jjosition of the Drug as a Remedial Agent. — This is
the practical question to which all the foregoing has been a
necessary, if lengthy, introduction. What is the truth about
Koch's lymph 1 Let us take a survey of the situation. Here was
a disease, of many forms, of universal prevalence, practically the
despair of the physician, and the dread of a large section of the
civilised world. Somewhat unexpectedly, after years of searching
and experimentation, the man most competent to speak, announces
the discovery of a remedy of a potency hitherto without parallel.
A miracle was, not unnaturally, expected, and the pendulum of
opinion swung irresistibly from nothing to the zenith. But the
days of miracles are apparently passed, and the unbounded hopes
13
of the previously hopeless were gradually — for the remedy had
that potency — disappointed. Criticism appeared, and it is
as difficult for scientific as for all other criticisms to be just,
especially when it is one rival individual and school reviewing
another, and one nation summing up the good works of its
foe. The miracle was, of course, impossible ; but, as might have
been expected, and as was predicted, the pendulum swung as
determinedly in the direction of the other extreme, and those who
had not secured a good personal footing were in great danger
of being swept away by the I'eturning tide. What, then, is the
truth about Koch's lymph ? I can, of course, give you only my
own opinion, and it is as follows : — I believe it to be a remedy
with a practically specific action upon tuberculous tissue, and that
within the limits already laid down, there is nothing which we at
present know to compare with it. From its potency, it requires
most careful handling, but we have already sufficient data to
render a wise use of it both possible and advisable. The question
narrows itself down largely into one of selection of cases, and
cautious administration. It would indeed be folly to assume that
we have attained anything like the best results — but the same
may be said of almost all therapeutic means — whilst it would be
still greater folly to decline the task of following on until greater
perfection is attained, Apart from its intrinsic value, it opens
the gateway to an almost unbounded field of fresh possibilities of
treatment. Already, Behring and Kitisato declare that they
have produced immunity against tetanus and diphtheria, and the
long inevitable thraldom of the infectious diseases generally seems
now to be within a measurable distance of overthrowal.
Coming now to particular instances, in uncomplicated cases of
lupus, administration is generally both easy, harmless, and exceed-
ingly effective, even in the doses mentioned by Koch. The tendency,
however, is towards a more cautious dosage, at more lengthened
intervals, and repeated for a longer period. Many relapses have
been noted where injections have been abandoned after a week or
so. Surely nothing else could have been anticipated. It is wise
also to remember the possible presence of other and even
unrecognised foci ; in complicated cases, the dosage is of course
proportionately diminished. As to the actual changes produced,
Schimmelbiisch (Bergmann's assistant) had, when I left Berlin,
numerous specimens taken from infected cases for purposes of
microscopic examination {vide also Kromeyer's paper). As
14
regards laryngeal cases, the services of a specialist are of course
indispensable ; and in selected cases, as will be seen from ray
summary, the balance of evidence is strongly in favour of marked
improvement, without serious risk. In bone and joint cases, I was
more favourably impressed than in any other part of the
treatment, and for the sake of suffering children alone, cannot but
regard Koch's lymph as of inestimable value. It may be the age
of the patients, or the peculiarities of bone and joint, or the
facility of operative assistance, or all combined ; but whatever be
the cause, certain it is that almost all observers are unanimous as
to the great good derived from Koch's injections in this variety
of cases. Hahn and Watson Cheyne's cases are particularly
instructive in this connection. In tubercular affection of glands
again, the evidence, though much less extensive, points generally
in the same direction. In developed tubercular meningitis, as
already stated, the remedy is probably too risky for use, though
the earlier diagnosis of tubercular mischief, which is given by the
lymph, may be used to prevent its onset. In tubercular disease of
the eye, exceedingly good results have been reported, but further
evidence is necessary before reliable indications can be laid down.
In tubercular disease of the uterus and appendages, Bossi, of Genoa,
considers it most useful. In cases complicated with tubercular or
amyloid disease, of intestinal, or genito-urinary tract, the use of the
remedy is no doubt almost always contra-indicated, or hedged
round with such individual restrictions that no general conclusions
are possible.
More or less agreement exists in reference to most of the fore-
going. The discrepancies begin to get more serious, however,
when we come to deal with pulmonary phthisis. The extra
difficulties of the problem in the case of the lungs, will suggest
themselves naturally to all. The main observers whose papers
seem especially noteworthy in this category are Koch, Guttman,
Fiirbringer, Gerhardt, Senator, Leyden, Yirchow, Theodore
Williams, Wollf, and Cornil of Paris. Extracts from these I
venture to read by way of illustration of my contention that the
successful application of Koch's remedy in lung cases is a question
mainlv of selection of cases and careful administration. From
this summary, supplemented by somewhat similar statements by
other observers, I think certain practical conclusions can be drawn.
(1) 'That cases of early phthisis where the mischief is slight, and
the strength good, and pyrexia absent, will in all probability derive
15
considerable benefit from the injections. (2) That in somewhat
more advanced cases it is a matter for some hesitation, having
regard to the power of the patient to expectorate, his habit of
doing so, the general health, the question of pyrexia, and rendering
the dosage both less in amount and less in frequency. So far
indeed from aiming at the production of reaction, by gradually
increasing the dose, I am inclined in many cases to suggest the
retention of a minimum close, and its exhibition twice a week over
a lengthened period. (3) That more advanced cases, and cases
with complications, should be injected, if at all, only after most
careful consideration, and only, if at all, as a last resort, and with
special precautions. And, speaking of the treatment of lung cases
generally, I believe that it is probable that it will be found to be
more beneficial to give minimum than increasing doses, and once
certain of the diagnosis not to aim at the attainment of other than
a continued slight reaction, having the patients under observation
for some months. By this means perhaps immunity may be gained.
As regards operative interference, it is certain that there is a great
future in cases of bone, joint, gland, and the like. Diagnosis can
be made earlier and with great certainty, and when operations are
undertaken, the results are often astonishingly good. The time to
operate, whether before or after injection, the local assistance of
iodoform, &c, to kill the bacilli, are questions which are ripe
for settlement. In pulmonary cases also, operative interference
becomes distinctly more hopeful. Before T left, Sonnenberg and
Hahn had recorded some half dozen of such, but the results were
too recent to warrant any exact conclusions. I am of opinion,
however, that in a certain limited number of cases, such as at
present tend almost invariably to get worse, operative measures,
combined with injection, promise at least considerable temporary
improvement.
After all, however, the future treatment of phthisis will
not in my opinion be able to neglect the general treatment, so
essential in the past. We shall still need preventative measures
against infection by dried sputum, tuberculous milk, and meat; we
shall need to build up the corporate vitality by all the aids in our
power, and shall value as much as ever the beneficial influence of
fresh air, sunlight, mountain climate, and diet. But with Koch's
lymph, or its perfected substitute, it becomes possible that we shall
"be able to confer immunity in cases favourably situated, and to avert
infection when otherwise it would occur. The future alone can tell
16
how near or how far we are from this splendid achievement. Even at
the present time, however, in my opinion, we can diagnose tubercular
disease at an earlier period, and influence it for good more by
the right use of Koch's lymph, than by all the rest of the whole
army of drugs.
Its Mode of Administration. — Dr. Henry has kindly translated
for me in Appendix C, Koch's own directions as to administration,
forwarded with each bottle of lymph. The dilutions, the dosage,
the precautions against contamination are there so explicitly laid
down, that all can understand.
Such then, gentlemen, is the report which I have the honour
to lay before the Victorian Branch of the British Medical
Association. The unparalleled enterprise of our Journal has
already furnished you with exhaustive accounts of almost all
phases of the question, and I am in hopes that this paper may
be found a useful commentary thereto.
It might be regarded, however, as a matter of discourtesy and
even misrepresentation, were I to conclude without paying some
attention to an official report upon this same question, published
over the signature of a Government Commissioner. It cannot
have escaped notice tbat there is a difference of opinion between
us, as to the value of this new method of treatment. It may be
that this difference is due to the fact that the time at the disposal
of the wi'iter of the report to which I refer, was unfortunately too
short, in my opinion, to have given him opportunity to dis-
embarrass his mind of the conflicting reports which were
necessarily rife at that early stage. In this respect, I certainly
had the advantage, as my stay in Berlin was prolonged to three
weeks, and embraced a later period, during which I was visiting
all the principal institutions at which this treatment was being
carried out. And in further justification of the position which I
have taken up, I would point out the fact that the author of the
official report seems to have missed the more recent literature,
which has had such an influence in crystallising our ideas upon
the question. I feel sure that had the same opportunities of
information which fell to my lot been enjoyed by our Govern-
ment Commissioner, he would have considerably modified the
conclusions at which he arrived. Thus, we now know a great
deal about the composition of the remedy. We have a good and
fairly satisfactory working hypothesis as to its mode of action ;.
whilst the dangers on which he dwells so heavily, turn out to be-
17
dangers of misuse, which are present in a small percentage of
cases only. And when he recommends " that for the present, in
accordance with Professor Koch's desire, it should be employed in
hospital practice only," he quotes — somewhat inaccurately it must
be added — from Koch's early paper. In his later paper, Koch
makes no such restriction, leaving the matter now to the common
sense of the physicians who had learned how to use the remedy.
For practical example, before I left Berlin and London, within
my own knowledge, Professors Leyden, Frankel, Senator, and
"Watson Cheyne, to say nothing of many others, were all treating
private patients as seemed to them best, and without any arbitrary
restrictions.
18
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34
Appendix B.
I have here collated some of the more interesting notes of
cases, the course of which I followed from day to day, supple-
menting them with the criticisms of the surgeon or physician
in charge, and such explanatory remarks as seem pertinent to the
occasion.
I. — At the Charite Hospital, with Professors Leyden and Gerluirdt,
and their Assistants, Klemperer and Roth.
The wards containing these cases were much overcrowded, and
far from commendable from a sanitary point of view. The
remedy was tried indiscriminately upon all stages of the disease,
with German thoroughness, and with a rapidity and size of dosage,
which I did not find anywhere else. It was almost entirely from
this hospital that Virchow's observations were derived. There
were quite a number of cases in which consolidations broke down
(the same was observed in other hospitals, but the moist sounds
disappeared under further treatment, and contrary to previous
experience and present expectancy, the chest cleared up after-
wards). There were also a number of cases with large cavities, in
which well marked reactions were obtained, the progress being
downwards It was the course of these cases indeed, which first
suggested to me the thought that, in seeking such reactions in
such cases, we were following a wrong line of action. Further
observations has shown that such is really the case. It is one
thing to produce marked effects in lupus and bone and joint
disease cases, where free exit is easy, or operative interference
intended, and even in early lung cases in otherwise strong subjects,
which can stand the reaction, and expectorate the increased
amount of sputum; but it is quite a different matter to hamper the
action of a vital organ already extensively diseased, by adding to
it the congestions, &c, of a strong local reaction. Before I left
Berlin, the tendency was rather to deal with such, if at all, upon
quite different lines ; to shun strong reactions, and to be content
with small ones ; and for that purpose, once sure your lymph was
potent, to give small doses less frequently, and over a longer
period, attempting in fact, slowly to vaccinate the part and the
system generally, against fresh infection, and slowly to affect the
large amount of tuberculous tissue already present. Almost all
subsequent experience seems in the same direction.
35
Thus from my note book, I extract the following cases : —
(a) Cavity formed in left axilla since treatment commenced,
hectic appeared, injections abandoned, but resumed, up to -01 cc,
temperature still high, lost five pounds in weight.
(b) Case of infiltration of the apex, broke down under injections.
(c) Two cases of large cavities with strong reactions, getting
worse.
(d) Case of cavity with slight reaction, improved.
(e) Case with dulness and moist sounds at right apex, in which
the dulness increased after the injections.
Around the room, also, you will find the charts, &c, illustrating
the following : —
(1) iEt. 12; incipient phthisis, infiltration of both apices, and
suffering since July 1890. Treatment started 20th November,
1890, with "0015, and increased up to '04 in sixteen doses.
Tubercle bacilli numerous throughout ; weight unaltered, 98 lbs.
Case improved, and note on 19th December, 1890, says, " At bases
things are normal ; in other parts, much improvement
(2) Infiltration both apices ; tubercle bacilli absent. On 22nd
November, 1890, treatment started with -002, ending on the 2nd
January, 1891, with -02. On 25th December, 1890, -04 given,
and temperature went up to 41-7° C. 19th December, little or no
change.
(3) Incipient phthisis ; infiltration right apex ; ordinary case.
Treatment started 24th November, 1890, with -002, ending 31st
December with -05. On 11th December, injection -20 caused rise
to 40° C. Results, not marked. Weight 113, 111, 114 lbs.
(4) iEt. 21 ; infiltration left apex, and retraction with bron-
chial breathing and pleurisy. Treatment started 23rd November
with -003, seventeen doses, to 27th December; -09 given then, and
no reaction then. No alteration in physical signs.
(5) JEt. 26 (medical student); infiltration both apices, more on
right side. Treatment started 27th November, 1890, with -002,
fifteen doses up to 27th December, when -09 is given, and no reac-
tion then. No tubercle bacilli found at all after 28th November,
1890. Weight increased from 116 lbs to 120 lbs (German).
Marked imprwement ; almost all sound clearing.
(6) Advanced phthisis; infiltration of both apices; tubercle
bacilli sparingly present. Treatment started 21st November with
36
•001, sixteen doses to 31st December, when -09 was given, with
slight reaction. Weight increased from 114 lbs to 117 lbs. Results,
not much.
(7) Infiltration both apices; bronchitis; copious expectoration ;
350 c.c. at start, decreasing slightly. Treated with -002 on the
24th November, up to -03 on the 27th December, in thirteen
injections ; last reaction 38-1° C. No history of progress given.
Weight increased from 122 lbs through 120 lbs to 123 lbs.
(8) 2BA>. 21 (smith) ; dulness, clavicular over and under; early
apical phthisis. History incomplete. Weight increased lib (111
to 112); numerous tubercle bacilli. Treated 27th November, -002
up to 30th December, -05 in fifteen doses.
(9) Mt. 36 (doorkeeper); trouble started March 1890; tubercle
bacilli numerous throughout; rales in apices; crackles in left apex.
Treatment started 27th November, '002 to *1 (27th December) in
fifteen doses. 23rd December, crackles weaker ; 29th December,.
all signs less marked, but still perceptible. Weight, 121 to 127 lbs —
gain of 6 lbs.
II. — At the University Surgical Clinic, under Professor Bergmann,
and his assistants, Schimmelbusch and Roth.
It will be remembered, that Bergmann began by being very
enthusiastic in favour of Koch's method. He seems, indeed, to
to have expected too much, and perhaps, as a consequence, left off
treatment too soon. Hence, in many cases, relapses occurred,
which necessitated another course of treatment. Still, his results
were such as no previous treatment could approach. Some thirty
cases of lupus were under experiment, besides numerous cases of
bone and joint disease, <fec. Here, also, they were using very large
doses, up to '4 ; ending, however, by giving less. Most of the
cases had been long under treatment, and were well-known as
inveterate, and otherwise incurable. The following extracts of
cases may be of interest : —
(a) Tuberculous Glands of the Neck. — Not much altered after
five weeks' treatment.
(b) Lupus. — After seven weeks, immensely improved; local and
general reactions good. Simply a reddened glazed skin left after
the exudation and scab came oil'. The affected parts now
altogether paler, with superficial scar tissue, and a few nodules
left behind the right ear.
37
(c) Lupus. — After seven weeks, also immensely improved ;
redness and swelling gone, but some suspicious brownish elevated
spots, which Schimmelbusch thinks may be lupus recedivus.
(d) Case of Lupus from England. — Colossal reactions ; up to
40°-41° C. ; dosage being -008 up to "4. An old coxitis became
painful after the first injection. Now all the crusts have fallen
off; the skin, though red, is even and desquamating ; altogether
wonderful improvement. The chart illustrating these reactions is
amongst those open to your inspection.
(e) Lupus of Nose and Face. — Nodules disappeared after three
injections.
(/) Case of Hip-disease. — During treatment, a lupus patch
appeared on the cheek.
(g) Lupus. — Injected on November 16th ; looking splendid.
(h) Case of re-appearance after suspension of treatment. Fresh
nodules vanishing when treatment resumed.
(i) Case of Lupus of twenty-nine years' standing. — Immensely
improved ; twenty-nine injections in seven weeks ; now up to "15.
Confirming the opinion that cases where the local reaction is
marked, do well.
(j) Child five years old, with Hip-disease. — Operation ; quiescent ;
tested up to -04 without reaction.
(k) Disease of Carpus. — No reaction after -01, but good general
and local reaction a week later, after same dose.
(0 Disease of Knee, in boy aged three. — Good reactions and
improvement; erythema, with injection ; went up to "01.
(m) In Hip-disease, set. 11 ; redness over malar bone after
injection.
(n) Three cases of Lupus. — Improvement, but fresh nodules
appeared.
(o) Ttibercular disease of Lungs, Neck, Arms, and Ribs, with
fistulae, in young man aet. 22.— Thirteen injections, from -001 to
•02, then without reaction; looking well; some of the fistulae
closed.
(p) In boy aet. 13, Disease of Skull, Elbow, Knee, Leg, Fistula;
in Neck. — Thirteen injections, up to "005, without effect ; strong
reactions.
(q) Extreme Case of Lupus, mouth and nose eaten away. —
Scraped 111 times. After eight injections upper part healed, but
fresh eruption on cessation.
38
(r) Tubercle of Larynx, man set. 31. — From -002 to -08, now
without reaction. Voice returned ; weight increased ; great local
improvement.
(s) Lupus Erythematosus. — Injected, but without effect.
(t) Lupus of Face. — Spot appeared on leg after injection.
III. — At the University Policlinic, with Professor Senator.
Here lupus cases and early phthisis cases were treated, between
9 and 10 a.m., in the out-patient department. Professor Senator's
name is sufficient guarantee as to the exercise of proper caution.
Cases came up, were examined, and, if severe or complicated,
admitted into the hospital. The procedure with those treated in
the Policlinic was as follows : — Careful notes were taken, the
Professor ordered the dosage, the patient was then and there
injected, and sent home. Later on, he was visited by a physician,
records taken and written in their note books, and the patient
advised as to his next day's procedure. The following day he
again appeared in the Policlinic, and was examined prior to
further treatment. In no case did I hear of any mishap. Both
Professor and patient stated that, in nearly all cases, there was
improvement both subjective and objective. One was struck here,
as indeed in almost all the wards, with the general appearance of
comfort, and absence of coughing. Professor Senator was very
well satisfied with his results. The average duration of treatment
he gave as eight to ten weeks. At his request. I visited one case of
lupus eight hours after his first injection. As illustrating his care
in ambulatory practice, I may add, that the dose was -002. The
lupus was of thirteen years' standing, and had been extensively
treated. I found the patient with the usual local and general
reactions well marked. One other case is worthy of record ; it
was one of lymphoma of neck and right lung, reacting, and said
to be improving.
IV. — At the Urban Hospital, with Professor Frdnkel.
This, and the Friedrichshain, are the two municipal hospitals
recently built, regardless of cost, upon the pavilion plan, and with
the most recent improvements. It would be difficult to surpass
them in any part of the globe ; the plan, structure, and arrange-
ments being perfection itself. At the former, I visited mainly
the medical cases under Friinkel's care. Here, as in La Charite,
almost all the beds were occupied by phthisical cases, and
39
professors who, as a rulo, had grown so tired of watching phthisis
tread its downward course, that they had become accustomed to
hand all such cases over to their assistants, were now devoting
themselves to the unusual task of attempting to do some real good
to these hapless sufferers — a token, truly, of the general hope-
lessness of the disease, and the importance attached to Koch's
manifesto. Professor Frankel was critical, and scientifically
sceptical. His cases bore ample evidence to the potency of the
lymph, but were not sufficiently advanced to draw conclusions.
His dosage was far more cautious than that adopted at the
Charite, and his record of effects the most suggestive and
complete. He noticed, with others, the marked improvement in
symptoms, upon which many dwelt overmuch, but marked the
want of equal improvement in physical signs, dwelling, in my
opinion, rather too soon upon this delay, and scarcely allowing
sufficiently for the fact that alterations in the physical signs were
not essential to arrest of disease, and even immunity against
fresh attack. The following were among his more interesting
cases : —
(«) Case in which tubercle bacilli were noticed in the excreta ;
absent before the injections.
(b) Case of nine months' duration, which gained weight, lost
bacilli, and generally improved with injections, gradually up to "I,
combined with creasote in large doses, and cod oil.
(c) Case of extensive consolidation ; bacilli present ; gradually
injected up to -02, and still reacting ; the bacilli not found on
repeated examination ; the Professor admitting that he would
think it a great result if his creasote treatment produced such
effect.
(d) Child ; phthisis, with pleurisy ; doing splendidly.
(e) Child, set. 13 ; injected -001 up to -01 ; had to stop the
injections, because became worse ; improved again on small dose,
to his surprise.
{/) Cases illustrating the effect of the lymph upon the bacilli ;
first a few, then plenty of bacilli ; then a few, then none.
(g) Cases illustrating the change in the character of the sputum
— nummular, pneumonic, mucous.
(h) Case, four weeks in hospital ; bacilli disappeared ; weight
increased two pounds, and no reaction now to -1.
(i) Case of incipient phthisis, nine months' duration ; plenty of
bacilli in the sputum, though no reaction to '1.
40
(j) Case, girl set. 16, with very slight signs; injection gradually
up to -1 in twenty-seven clays, with practically no reaction ; then
with -1, rise to 104°, hectic, plenty of sputum, lots of bacilli, and
locally, breaking down ; now again improving very noticeably ;
typical of several others.
(&) Case of diabetic phthisis ; injected one month ; sugar van-
ished, but bacilli still present. (In diabetes without phthisis, no
effect after -008).
(I) Phthisis, with tubercular otitis ; improved by -007, but
bacilli still in discharge.
(m) Case of stationary phthisis; injected -001 to % without
reaction.
(«) Case of lupus of palate and larynx, with tubercle of kidney ;
no reaction even to -07.
(o) Case of haemoptysis ; -1 in seven days, the hajmoptyfjis
lasting three weeks.
Around the room, you will find charts which illustrate the
foregoing.
"V. — At the F riedrichshain Hospital, with Professors Ilahn and
Fiirbringer.
This hospital and its results pleased me most of all in Berlin.
The hospital itself is second to none, and its medical and surgical
directors seemed to preserve their equilibrium under circumstances
which swept away the common sense of many. Both began by
being sceptical of the good promised in Koch's lymph, and both
found reason, after trial, to entertain a more favourable opinion.
Taking first Ilahn' s Surgical Cases. — It was the clinical sight of
my visit to see the number and variety of tubercular cases, daily
visible in the superb operating theatre at Friedricbshain, and to
watch their general progress towards improvement. In most
cases, Ilahn had been driven to inject the cases by the entreaties
of their friends, operating after seven or eight injections, and
finding the injections had been a wonderful help, so that he was
able to see all the diseased tissue, remove it with certainty and
ease, and leave apparently healthy tissue behind. Later on,
however, he thought it better, in some cases at least, to operate
first and inject afterwards— the bacilli, <fcc, escaping through the
vent thus produced. He likened the therapeutic use of the
lymph to that of mercury in syphilis, and regard its diagnostic
41
power as practically certain. Out of many, I select the following
examples : —
(a) Syphilis of Elbow-joint. — No reaction with the lymph ;
good results from mercury and iodide of potassium .
(b) Inflammation of Knee. — No history of tubercle; no reaction
after -005, but typical reactions after -01, and bacilli found in the
joint.
(c) Local reactions well shown in case of Phlyctenular Conjunc-
tivitis, followed by improvement.
(d) Tubercular Disease of Pelvis, with fistulse. — Results not so
good.
(e) Lupus Hypertrophicus. — Ten years' standing ; slight re-
action after -005, then given -01.
(J) Hip Disease. — Great reaction; operation; still great reaction
after -003 ; weight gained and general health much improved.
(y) Lupus in Child. — Extensive and spreading ; injected -001
to -004 ; still reacting, but healed above and below, with clear
skin between.
(h\ Hip Disease. — Frequently operated upon; always recurring.
Now, after injections up to -006 and operation, the state of the
parts is better than Hahn has ever seen it before.
(i) Knee, in child 1^- years old. — Sequestrum removed from
patella; injected with -00 15. Now, no reaction ; great improve-
ment ; increased two pounds and a half in weight.
0) Spondylitis of Hip in child, aged four. — Great reactions;
walked after the seventh injection, and put on three pounds in
weight ; no other treatment, not even extension.
(k) Knee. — Anchylosis, with fistula?, in boy, aged five ; injected
•0005 to -005 ; resected ; healed unusually quickly.
(I) Case in which the third reaction was much the largest ;
typical of many. Further, upon the walls you will find charts
illustrating the following : —
(m) Old Coxitis, with fistulse, fifteen years' standing ; resection
before injections ; after eight injections -005 to -008, the fistula?
healed ; great success ; seeming cure ; reactions always slight.
(w) Chronic Pyo-nephrosis. — Operated upon witliout diagnosis of
tubercle. Injected '002 four times, with immediate great reaction ;
decrease of suppuration.
('>) Lupus of Nose, three years' duration ; often treated, but
always recurring. Ten injections -002 to -01 ; great reactions,
local and general ; very greatly improved.
42
(p) Knee in girl, aged eleven and half years ; no success from
previous operations; seven injections from -001 to -006 ; violent
reactions ; re-resection ; then almost no reactions with the same
injections and striking improvement.
(q) Typical reactions in lupus after doses of -005, disappearing
after the fourth dose. For these, and for many similar favours, I am
indebted to the courtesy of the Resident Officer, Dr. Gumprecht.
Upon the medical side, Professor Fiirbringer's cases were
equally noteworthy. Unfortunately, however, for me, the visiting
days were restricted during my stay, so that my clinical opportuni-
ties were minimised. One could not help noticing, however, the
tendency to employ small and not increasing doses not oftener
than weekly, or at most, twice a week. There was, also, the
great care in the selection of cases, and the promptness to abandon
the use of the lymph where the disease was becoming worse.
The Professor showed several cases "provisionally cured," and
many which had progressed better than any in his previous
experience. Upon the whole, his results were most encouraging,
and his cautious testing of indications for treatment most sug-
gestive. His future records of cases under treatment will, I feel
convinced, be of unusual clinical value.
At this hospital, also, I saw one patient who had been operated
upon two days previously for pulmonary cavity, and I was present
whilst another was similarly treated. In the former, there had
been a cavity at the right apex. After the operation, the
temperature scarcely rose, but the pulse was 140 and 128, and the
respirations 56 and 40 on the two following days. The wound was
dressed with iodized mull ; there was no drainage- tube, and as
yet, the patient had not been injected. The size of the cavity was
tested by warm water introduced through a tube, and also by
means of a probe. The cavity held 400 cc, and the Professor
drew its outline on a black board. An injection of "001 was
ordered, the Professor remarking that if he could be sure of
adhesions behind, he would drain the cavity right through. Upon
the same day, another case was operated upon. The man, who
was pale and anaemic, had a large cavity at the left apex. Under
chloroform, the surface was washed with carbolic solution, and a
long incision made, great care being taken, by forceps and
ligatures, to prevent any bleeding ; the intercostals were separated,
and a hollow probe attached to a syringe, passed into the cavity.
Once sure of the position, a Pacquelin cautery was passed along
43
its track, and repassed, as the cavity was deep-seated ; the wound
was dressed with iodized mull. It remains for the future to show
what results may he expected by such procedure.
VI. — At the Augusta Hospital, with Professor Eivald.
This is a good, but small, hospital, and I visited the medical
cases rather to extend my basis of observation, than to study them
in detail. Practically, the results were, upon the whole, very
promising, both subjectively and objectively ; rapid improvement
seemed frequent, and great care was taken with the dosage. The
main question indeed was, not so much the value of the treatment,
as the indications for and against its use. The Professor's own
account of his experience, is to be found summarised in Appendix
A, and supersedes my notes.
VII. — At the Moabit Hospital, under Giittman and Sonnenberg.
Here were the cases assigned to Koch himself, and in reference to
them, I cannot do better than refer my readers to Guttman's
papers, published in December and January {vide Appendix A).
Taken with Fiirbringer's, &c, they will be found to support Koch's
contentions as to the value of his lymph, and to show how dosage
and frequency of administration are points of supreme importance.
I had the opportunity here also of seeing two of Sonnenberg's
cavity-operation cases.
VIII. — At the Hygienic Institute.
This celebrated bacteriological laboratory I visited first, in the
hope of seeing Professor Koch, only to find that he had left fifteen
minutes previously for a holiday in the mountains. Upon subse-
quent visits, I was shown round by Mr. Hankin, to whose work in
reference to anthrax and albumoses, I have already referred.
Besides seeing Brieger, Fraenkel, Weyl, Shakspeare, and others
at work in their separate researches, I had the — to me —
unbounded satisfaction of seeing the animals that Koch had
rendered immune against tubercular infection, by means of his
lymph. It is scarcely too much to call this performance one of
the greatest achievements of the century. Apart from all other
evidence, it makes it almost certain that it is only a question of
time and testing, to confer similar immunity in the case of man.
I also saw the animals that Behring and Kitisato had rendered
immune against diphtheria and tetanus. Such far-reaching
experiments could not but raise one into a new therapeutic
atmosphere, where the doings of science seemed about to rival tho
marvels of tradition.
44
IX. — At the Pasteur Institute, with Pasteur, Roux, <kc.
My visit to the corresponding French home of bacteriological
research may be appropriately mentioned here. Armed with an
introduction from Mr. Hankin, I was welcomed by Dr. Adami,
introduced to M. Pasteur, and shown over this model of all
laboratories. It may be questioned whether there is any place of
greater scientific interest in the Europe of to-day. To look on it
was a jnuvilege and an inspiration. Its Annales are among the
glories of our time. The matter of greatest interest during the
hours of my visit, was the inoculation of some sixty patients
against hydrophobia, by M. Roux. The completeness of the
arrangements was beyond all praise. One could not help thinking
how much Koch himself owed to Pasteur; how worthy a successor
he had proved himself to be, and how the success of the parent
institute augured well for the fulfilment of the hopes of its
German relative.
X. — At the Victoria Park Hospital, with Dr. Heron.
To widen my basis of comparison, I visited London for the
purpose of ascertaining how far English experience supported
Continental. At the time of my visit, Dr. Heron was the
authorised and main exponent of Koch's treatment, as far as
pulmonary cases were concerned. As suggestive records of his
cases are to "be found in Appendix A, I will deal here simply
with generalities. Dr. Heron was observant and painstaking to a
degree. His experience and results may be classed in the same
category as Fiirbringer's and Giittman's. He was soon led to
select his cases, and to observe caution in his dosage ; and, as a
result, he stated himself that he was more hopeful in his treatment
of cases of pulmonary phthisis, than ever before.
XI. — At King's College, ivith Mr. Watson Cheyne.
Here were collected together most of the surgical cases under
treatment in London, Mr. Watson Cheyne having been deputed
to deal with such. Upon the whole, they bore out the favourable
opinions expressed by Hahn, Bardelebin,and others in Berlin. Some
were of extreme interest. I take the following from my notes : —
(a) Man, aged 30 ; Glands in Neck and Axilla for five years,
steadily increasing ; eighteen injections up to -02 ; strong re-
actions ; operated, and removed cheesy parts with a scraper ; all
non-cheesy parts had been destroyed ; now doing extremely well.
(b) Child with Dactylitis and Sinus in Buttock for twelve months;
seventeen injections, -002 to -012 ; operation; much improved.
45
(c) Child, aged 10 ; Disease of Internal Condyle of Elbow. —
Operated upon several times; nine injections, •003 to •01; now no
reaction ; very much improved ; sinus almost healed.
(d) Child 5, Knee affected. — Only first reaction good; extension
continued ; very much improved.
(e) Lupus, fourteen years' duration ; great reaction after -002 ;
scarlatina rash ; locally, scabs and redness.
(J) Lupus of Thigh and Axilla in boy of 15 ; seventeen injec-
tions in six weeks, up to -1 ; improved immensely at first, now at
standstill ; still reacting.
(g) Sinus in Os Calcis. — Twenty-one injections, to '15, lessened
to -1, because of cardiac pain; no reaction since the ninth; no
previous good from any treatment.
(h) Acute Knee-joint in boy of 9. — Worse with extension; going
rapidly to the bad; six injections, up to "013; immensely improved.
(;') Man, aged 22 ; Diseased Elbow. — Opened, scraped, arthrec-
tomy ; still septic sinuses and swellings round the joint ; sixteen
injections, up to -08 ; improving.
(j) Disease of knee in man of 32 ; immensely improved after
eighteen injections, "01 up to '2.
(k) Hip, double excision ; '01 to *1 ; ever so much better ; one
sinus healed ; only one open sore left.
(I) "Woman; swollen knee. After two injections, old scrofulous
scars on the right arm reacted.
(m) Hip. — Three weeks' history ; could only be drawn up with
difficulty ; no treatment except injections ; in six weeks eighteen
injections, -003 to "01 ; good reactions; now all movements possible.
(n) Old Abscess in Elbow. — Fifteen injections, -003 to -02 ;
operation; much easier, and results better.
(o) Lupus in girl of 26; scraped thirty times; sixteen injections
up to -12 ; practically healed ; no trace of disease left.
(p) Disease of os calcis and astragalus in child of eighteen
months ; eighteen injections, up to -008 ; still reacting.
(q) Diseased Elbow. — Twelve months' duration ; getting worse
with rest, splints, &c. ; after injections, swelling much less, and
movement freer.
(r) Two cases with septic sinuses, and temperature raised ;
injections had to be stopped.
(«) Disease of Spine, with iliac abscess. — Not healing after
operation; sixteen injections, "006 to 015. Now, the lumbar
wound healed, and cannot pass a probe.
46
(t) Hip Disease, with great shortening. — Fifteen injections,
from -002 to -02 ; one injection on to the hip, followed by a local
abscess.
(u) Lupus in man of 60. — Great improvement ; still reacting
to *1. Cheyne arl vised continuing twice a week after local
reaction has ceased, to try to establish immunity ; thinks
recurrence probable where the dose is abandoned too soon.
(v) Child, acute disease of Knee. — Injected up to '02, with only
slight reaction. Now, can draw up the knee.
(iv) Leper. — Twelve years' history ; anaesthesia, with con-
tractions of hands and toes ; also, half-way up the leg. After
injection, macular rash, bulla? on the legs, loss of pain, and able to
open the hand.
XII. — At the Brompton Hospital.
Dr. Kershaw kindly showed me the sixteen cases of phthsis,
and two of lupus, under treatment at the time of my visit. The
experience was too limited to warrant definite conclusions. They
were of opinion, however, that early cases showed improvement ;
the doses were small, and the reactions slight.
XIII. — At the London Hospital.
Dr. Galloway was good enough to show me round. There were
only a few cases of phthisis, the doses were small, the reactions
slight, the lymph apparently relatively weak. A few lupus cases
were reacting nicely, and showing improvement. Altogether,
treatment was only beginning.
Appendix C.
Directions for using Koch's Lymph.
The remedy will keep for a lengthened period. The dilutions
on the other hand, which have to be specially prepared for the
purpose of treatment, are easily destroyed and become cloudy.
Fluids which have become cloudy must not be used.
In order to preserve the dilutions, it is necessary to boil them
every time the vessel is opened in which they are contained. This
is however rendered unnecessary, when the dilution is made with
a half per cent, carbolic acid solution.
The dilutions are made by first manufacturing a solution of
10 per cent., which is done by adding to 1 cc. of the lymph, 9 cc.
47
of distilled water, or of a half per cent, of carbolic acid solution.
In the same way, a 1 percent, solution is prepared from the 10 per
cent, solution. In this manner, the necessary dilutions are
obtained for the treatment of adults. For children, it is advisable
to make further dilutions, for example, to a half per cent.
As the weaker solutions lose in potency by being kept, it is as
well to prepare a fresh quantity whenever it is required. If in
making the dilutions distilled water is used, then the same must
be sterilised by poui-ing the liquid into test tubes, plugging the
month of the tube with cotton wool, and allowing the fluid to boil
over a gas jet or spirit of wine flame.
The remedy is introduced into the system by means of subcu-
taneous injections, and experience has shown that the best spots for
hypodermic injections, are between the shoulders and in the lumbar
regions. The injections are best carried out by means of a sterilised
Koch's syringe of a capacity of 1 cc. and divided into ^ cc.
In order to sterilise the syringe, it suffices to wash out the
cylinder and the needle with absolute alcohol. By doing this,
abscesses are avoided.
If an ordinary Pravaz syringe is to be used, it must be
thoroughly sterilised before using by means of absolute alcohol,
but even then abscesses are not altogether avoided.
The course of the temperature must be observed, both before
commencing the injections, and afterwards. It is necessary to begin *
taking the temperature every three hours, at least, one day before
the first injection, and to see that this is regularly carried out
during the whole period of cure.
The injections are to be made in the morning, in order that the
effect it produces, particularly on the body temperature, and which
only shows itself after some hours, may be observed on the same
day.
In cases of pulmonary consumption, the strength of the first
injections to be used, should be 0-001 or 0-002 cc. of the lymph; this
quantity is obtained by injecting up to one or two division lines
of the syringe, with the 1 per cent, dilution.
During the next days, the dose is cautiously increased. In case
the fever reaches above 38-5 (101-3° F.), the dose is repeated, or even
left off; or if only slight fever, or none at all shows itself, then
the dose is increased by 0-001 to 0 002 cc. If at last a dose of
0-01 cc. has been reached, it may be still further increased, while
carefully observing the temperature, by 0'01 or 0*02 cc. If the
48
daily dose has reached O'l cc, then as a rule it does not require to
be further increased. In only exceptional cases will it be necessary
to go as high as 02 cc, or more. The injections are continued
with interruptions of one or more days, until the symptoms of
disease have disappeared.
If the case is one of not very extensive lupus, the first dose may
be begun at once at 0-01 cc, and according to circumstances
repeated. This same instruction applies to bone-joint and
glandular tuberculosis.
The correct preparations of the lymph can only be guaranteed
if it is procured direct from Dr. A. Libbertz, Berlin, N.W.,
Luneberger Strasse.
STIIXWKLL AND 00, PRINTERS, 195A COLLINS STREET.
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